A Veteran Psychiatrist/Parent/Writer Observes the American Culture

Public health

A few posts ago I wrote about the emergence at Methodist Hospital in Houston TX of the truly antibiotic treatment-resistant Klebsiella bacterial strain. The infectious disease and internal medicine clinician researchers had been following the presence and prevalence in patients in the ER and hospital wards since 2011 through 2015. They had recently published their results in the prestigious journal Nature.

Methodist Hospital had been tracking this dangerous bug since it was noticed in patients in that hospital in 2011 or slightly before. The Methodist Hospital clinical researchers had tracked large numbers of patients both at risk and not at risk for harboring “bad” germs such as the better known MRSA [methcillin resistant Staph Aureus bug] as all hospitals have done for over a decade or more as standard procedure upon any admission to a hospital. They were taken aback and I dare say, medically frightened by their findings that larger than expected numbers of patients had this resistant Klebsiella.

Well, now it turns out that an equally antibiotic-resistant bug, a variant of our old Gram-negative E. Coli bug has turned up in Alabama centers in an alarming incidence that cannot be ignored either. This I fear really fear is the start of what all of us in public health, medical epidemiology, infectious disease and internal medicine have anticipated for years, the start of the antibiotic resistant age with multiple bacteria being antibiotic resistant.

For several years, the strategy in treating moderately resistant bacteria has been to employ typically dual or triple antibiotics to treat infections and this has until recently been quite successful. But the thinkers and ponderers in medicine, even in psychiatry such as those who practice in large hospitals and see patients in growing numbers with medical conditions that predispose to resistant ‘bugs,’ such as modern immunocompromised patients engendered by our novel non-chemotherapeutic anti-cancer drug regimens that do not utilize ‘cell poisons’ as in the beginning days of oncology and HIV patients who are immunocompromised out of hand because of the way the HIV virus operates and its routine effects on suppressing the immune systems of the body. I myself am partially immunocompromised by the treatment I do daily for multiple myeloma and have had a few episodes of serious body-wide infections or sepsis and face with some degree of trepidation this new issue of antibiotic resistant bacteria. But a number of other populations fall into these vulnerable categories, such as infants, children, the elderly, persons on the new drugs for rheumatoid arthritis and psoriasis. These are not small elements of our populations worldwide by any means.

So without really any or too many new wonder antibiotics on the horizon to save us all, the researchers are scramblers as fast as possible in another direction that likely is better. The development of vaccines bears promise and bacteria do not change and morph and trades parts of DNA in their annual changes such as in the various flu strains and so present hopefully, slower moving targets for vaccines. It appears we will enter into a new era of vaccine research and development since the days of the polio vaccines and childhood disease vaccines.

I also would throw down the gauntlet to the anti-vaccine movement parties in this country, for whom I have a great deal of antipathy for generating in my view truly ‘fake news and information’ about the supposed harm of vaccines and causing such alarm among the relatively less educated and even well-educated parents of the last 20 years or so to let their children go unvaccinated. Because of this, we are having more and more outbreaks among the much larger cohorts of the unvaccinated of measles, mumps, whooping cough and even diphtheria as the collective “herd Immunity” is diluted by the larger numbers of unvaccinated children at the mercy of their misinformed parents. And yes as a physician I am well aware of the tragedies caused by the RARE cases of PANDA syndrome, catastrophic CNS cases of brain damage due to encephalitis which things like measles cause in large numbers in severe cases in the unvaccinated in addition to deafness and other tragic consequences. One could hope that the anti-vaccine ill-informed and just plain dead wrong movement in this country and others would wake up when the realities of the antibiotic resistant bacteria start causing widespread deaths and the only defense against them on the horizon or on the pharmacy shelves is bacterium-specific vaccines. Then when they, their elders, and their children are threatened in very real stark life and death terms, I would hope to God that they come to their rational modern day senses.

It seem to the casual observer, and I will include myself in that category on questions much bigger than me often, that in the War on Drugs, it is like the county fair “Whack-a-Mole” game, where you hit on pop up mole head down into its hole and another pops up over and over. With drugs we have still a plethora of illicit more damaging than every agents available, but as soon as we may progress on one drug of abuse’s “front,” another bounces up into increased availability to take its place for a while. And so it goes with marijuana and meth, interdiction has been seizing more and more in the last few years and now heroin supplies have surged again becoming every more obtainable again on the streets. One factor sadly is that a few years ago the American military had to make the tactical decision to stop the eradication effort on the poppy plant on the growing high planes of Afghanistan to save that country’s local economies, and to “win the hearts of the people,” the old concept from many previous wars, made most ‘popular’ in the Vietnam Conflict/War. Heroin is showing up again everywhere, the streets, points of interdiction and seizure, and in the ERs across the country.

An October 3, 2014 report “Increases in Heroin Overdose Deaths–28 States, 2010 to 2012,” from the venerable CDC’s weekly mortality and morbidity report, the MMWR showed the increase in heroin to be quite real with data covering 56% of the country’s population showing in the first line that the prescription drug abuse and overdose epidemic 1999-2010 has been massive, stating: “Nationally, death rates from prescription opioid pain reliever (OPR) overdoses quadrupled during 1999–2010,” but then subtly noting that heroin OD death has increased at a slower rate during that period of time. The report then goes on the document step by statistical step, that heroin use and rate of overdose deaths increased after 2010 dramatically. It showed from data solicited from all states with responses from 28 states for just the two year period from 2010 till 2012, that “The death rate from heroin overdose doubled in the 28 states from 2010 to 2012, increasing from 1.0 to 2.1 per 100,000 population,” effectively doubling in that short of a period of time! Further the report found statistically and accurately that heroin overdose deaths increased nationally in every age demographic, not just the young adult segment of typically the early 20’s to mid thirties, and that the OD death rates increased also in females a trend not always seen. The report goes on the compare in effect time periods of heroin high rates of use with the current period and states telling: ” In a sample of heroin users in a treatment program, 75% of those who began opioid abuse after 2000 reported that their first regular opioid was a prescription drug. In contrast, among those who began use in the 1960s, more than 80% indicated that they initiated their abuse with heroin (8). Persons who initiated heroin use after 2000 have reported that heroin often is more readily accessible, less expensive, and offers a more potent high than prescription opioids.”

There was a national increase in heroin overdose deaths of at least 45% in the years 2009-2012; states had increases in the time period 2010-2012 of from 74% to 300%!!!

So it is clear the heroin scourge is with us again, proving sadly and tragically that history repeats itself,” that addictive waves of old drugs “come around again,”

I fear that each generation must learn its developmental lessons all over again for itself, such as how to study in school, how to get toilet trained, how to share with other kids in the sandbox, dropping out of school means economic serfdom or condemning yourself to the illegal underground economy, tattoos are hellishly painful and expensive to have removed by your friendly expensive dermatologist even with a laser when you realize they are dumb and keep you from getting hired sometimes, that binge drinking really is bad for you and not worth the pseudosocial rank it seems to afford you in your equally stupid peer group who fail their exams just like you did because of it, that prolifigate sex will eventually teach you an unwanted lesson, and working in a low level service job will not pay for all your “Tunes” and the expensive Nikes your mom and pop used to buy for you in the old days, that your friend and apartment roommate will not pay the rent and steal you blind when you throw him out and then realize you cannot afford the rent by yourself…And that heroin will addict you and can very well kill you like it did Jerry Garcia of the Grateful Dead in 1995, who as bright as he was, was an absolute idiot when it came to heroin and speedballs, dying IN a treatment center and betraying his fan base to boot. [As an aside yesterday I viewed his last interview in ?August 1995 very shortly before his death, and he was high, loose, disorganized, funny but pathetic, an old man who had not learned anything…] At least David Crosby came to his senses reportedly when he needed a liver transplant and realized what he had done to himself, and Robert Downey so far has demonstrated the power and benefits of sustained recovery.

So our public education efforts on heroin will have to ramp up again at all levels, and the War on Heroin specifically will increase once again targeting the cartels and gangs and God knows who else. And hopefully the greedy legislators in this country in order to fulfill their mantra of renewed Voodoo economics so ably and foolishly tried again by Governor Sam Brownback in Kansas, will not seizure upon legalizing and taxing heroin to make up for their moronic self deluding state revenue reducing policies that result in the chaos now repeating itself in Kansas, the land of sucker legislators, disappearing revenues, huge new budget deficits in the cautious Heartland of America (Crazy California yes, but not rock steady sensible Kansas. And if the “good Governor’ destroys the economy there and sends it into bad bond rating territory because now deficit borrowing, self induced tax raises (oh my what the Republican Governors’ caucus think of him now?), no more best buddy status for him…then he can count himself as stimulating the underground economy and drug i.e., meth manufacture and sales, increasing sales and distribution of heroin, if the marginal folks have no where else to turn to work and we will replication of what has happened in white Appalachia repeats itself in the Heartland, which stereotypically and simplistically thinking, is almost “unthinkable.”

One of the most recent news reports, from NBC News, June 17, 2105 entitled “Drug Overdoses Spur Rise in Accidental Deaths,” On the general level even, its statistics are startling: “drug overdose deaths have doubled in the last 14 years”; “drug overdoses killed 44,000 people in 2013” [more can car accidents!]; “more than half of these deaths, 51.8%” were related to our now well known prescription drug abuse epidemic, “with more than 16,000 deaths related to prescription painkillers…” West Virginia, one of the chronically poorest and of recent years with the downturn in the coal and timber industries, has topped the list consistently for accidental drug overdoses in this country. Suicides, are still the second leading cause of injury deaths, accounting for 41,000 annually, while motor vehicle accidental related deaths are third with 33,000 but noticeably continue to decrease over time. I can remember when I was in my youth that MVAs killed on average 55,000 annually consistently UNTIL the great organization MADD, Mothers Against Drunk Driving, identified the main cause as drunk drivers, especially recidivist drunk drivers, and started the national pressure campaign and hastened the long needed legal and enforcement crackdown on drunk drivers, with longer prison sentences even without death involved, for repeat offenders. Well into this report comes the subtle point that heroin now again is making up a large part of accidental drug overdoses, and that again “Heroin use [is] on the upswing again.”

One of the very understandable, beliefs, and possibly myths, about the past few decades of mass shooting incidents this country and others have suffered in a seemingly increase in occurrence of these horrific events, that most if not all of the shooters are “crazy,” or psychotic, actively mentally ill, deranged or just plain “off the chain.”

One of the earliest riveting examples of this was the ?Long Island Railway shooter of a number of years ago, who went on a shooting rampage killing a number of passengers randomly. It did turn out that he was indeed very psychotic and had been suffering from a major unchecked psychotic disorder, and that his shooting rampage was delusionally driven. This came out at his trial very clearly through testimony. His case was one of the national consciousness level cases that locked this sometimes erroneous impression into the national psyche and elevated such a rare fluke like event to a nearly universally accepted knee jerk easy explanation whenever another of these incidents occurred. This was driven by the reassuring power to all of us at some level that we were ‘by odds’ safe from ever coming into the sights of such a rare individual.

However this method of distancing ourselves from the arena of the fantasied “remote” possibility of such a tragedy touching our lives was strained as it seemed that seemingly an everyday Joe husband, with over controlling jealous though often unsupported rages killing their wives were found not to be mentally ill and acting out of a different social phenomenon. The beginning of the school shootings, perhaps the one of Arkansas a number of years before Columbia in which literally a young middle school student commandeered his family’s rife and started sniper shooting at his school mates began to jolt the national explanation out of credibility and point toward a more unsettling state of affairs, that one did not have to be stereo-typically “nuts,” crazy,” or psychotic, that ordinary persons including kids could suddenly be moved to commit such horrendous acts.

It started to be harder and harder to maintain as the automatic self reassuring explanation that made one feel safe if one was able to attribute the cause of the next incident to a mental vision of the very rare deranged killer who popped up out the lottery bowl ping pong ball numbers making their appearance “against all odds.”

Now comes a study that proves that psychotic symptoms, the behavioral and mental markers, identifiers, characteristics and legally accepted criteria for psychotic mental illness mostly are NOT present in the make up or motivating factors of mass shooters and are NOT the driving cause for their shooting episodes.

This article entitled “Hallucinations Rarely Precede Mass Shootings, Originally Posted by Yasmin Anwar-UC Berkeley on May 13, 2015,” makes for enlightened reading and offers welcome, though unsettling, additional information and increased basis for understanding somewhat more fully the motivations of the modern mass shooters from teens to adults. The research proven fact derived from interviews post shooting acts conclusively shows that the vast majority of mass shooters did not have psychotic symptoms such as delusions or hallunications driving their acts of mass shootings as is more and more commonly thought by the public and it seems by our all too superficial national media in their hyperdrive for easy explanations for the news events that cover endlessly to fill the bottomless pits of 24 hour a day news cycles.

Some of the more relevant and somewhat startling points of counterintuitive knowledge include:

that a literature review of over 300 violent incidents in the United States found only 12 percent occurred in the setting of active psychosis and were derived by the false beliefs an perceptions that are part and parcel of actively psychotic mental states.

Other foundations and reasons for such violence involved brutality, anger toward separated spouses, rampant substance abuse and access to firearms at the times of heightened stimulant states to violence. These were far, far more common precipitants to mass violence than elements of psychosis.

“High-profile mass shootings capture public attention and increase vigilance of people with mental illness,” says lead author Jennifer Skeem, a clinical psychologist and associate dean of research at the School of Social Welfare at the University of California, Berkeley, stated in the study: :our findings clearly show that psychosis rarely leads directly to violence.”

Researchers focused on the most violent patients tracked in the MacArthur Violence Risk Assessment study, a major 1998 analysis of more than 1,100 offenders who had been discharged from psychiatric facilities.

Specifically, they looked at a subgroup of 100 high-risk patients, who had been involved in two or more violent incidents in the year after they were discharged from a psychiatric facility, to establish their mental states at the time they committed acts of violence.

“We wanted to examine the small group of people with repeated violence and see how consistently these violent incidents were caused by hallucinations and delusions,” Skeem says.

In a preceding study headed by Dr. Skeem, records of prior mentally ill offenders who has committed severe acts of violence were interviewed about what they were thinking and feeling immediately before they engaged in the acts of violence; as an additional source of corroborating data, the retrospective information their friends and family members had to contribute about the times of the offenses were collected.

The very telling finding was proven that psychosis occurred prior to the offenses and multiple violent acts in only 12 percent of the violent acts these patients who had been incarcerated for their offenses following their release for these acts! Far more telling was the finding was the common circumstance that in subsequent violent acts in these offenders whose prior acts HAD been committed in states free of mental illness.

For the last few months in the Boston Marathon Tsaronov trial and the Batman Theater Killer shooting in Aurora movie theater trials, we have been and will be further subjected to the confusing airing of definitions of psychosis in legal terms, whether the shooters were suffering from mental illness or not. There may even be yet another “battle of the experts,” of forensic examiners who draw diametrically opposed conclusions about the mental mind set of James Wilson, Colorado shooter. These cases usually further confuse the public who cannot be expected to be intimately familiar with the complicated and subtle fine points of legal definitions of insanity as it relates to legal culpability. Yet these differences between the long evolved legal historical bases of legal insanity and psychiatric clinical definitions of insanity/psychosis have been essential for rational use by the criminal justice system to make functional decisions of such portent.

These trials and the inevitable future similar trials as further perpetrators of mass shootings and murderous violence, will hopefully gradually elevate the public’s grasp of the bases for our country’s determinations concerning these baffling and crimes with causative factors that almost always involve factors and long evolved highly personality motives outside the experiences of nearly all of the rest of us.

For months now, I have been mulling over in my mind, writing a number of posts on the anti-vaccination movement, both historically going back to the days of Joseph Lister and the original cowpox experiments, and the recent anti-vaccination movement in this country.

At this outset I will reveal my biases about vaccination in the interests of so-called “fair and balanced reporting” our modern catch phrase in the media that claims impartial reporting in the various media. I am a physician first and a psychiatrist second. I believe in the “common weal,” the common good as a physician who believes in the value of public health prevention. Otherwise we would have open sewer channels in the streets of congested urban areas as in the times of Charles Dickens, and horse droppings in the streets, public sewer systems and so on. I still hold comprehensive, accurate and impartial food inspection systems are vital to a society’s health. I thoroughly believe in public health screenings in public schools, for instance for vision, for aggressive mammography screening programs for women for breast cancer. I believe firmly in the concept of “herd immunity,” as vital to public health efforts. I support the Bill and Melinda Gates’ Foundation’s efforts to vaccinate the vulnerable populations of the Third World, countries with almost nonexistent public health systems, to vaccinate populations to eradicate malaria. Continue reading →

I am old enough to have lived through as a very young child, but a fearful one, the polio scares of the 1950’s. I saw on early television that visions of children and adults living in the “iron lungs” being unable to breathe on their own. I recall that my parents were caught up, as were most parents of those times, in the misplaced but gripping fears that polio could be caught in public swimming pools and that I could not go swimming.